Basic Information
| Provider Information | |||||||||
| NPI: | 1861533770 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAYNOR | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6870 W KATHLEEN CT APT 7 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531329220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144675055 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8701 W WATERTOWN PLANK RD | ||||||||
| Address2: | DIVISION OF NEOPLASTIC DISEASES | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148054600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 01/23/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 1304 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 43892300 | 05 | WI | MEDICAID | 682370078 | 01 | WI | MEDICARE PROVIDER NUMBER | OTHER |